1 patient safety is job one patient safety new-comers orientation evans army community hospital
TRANSCRIPT
1Patient Safety Is Job One
Patient Safety Patient Safety New-Comers OrientationNew-Comers Orientation
Evans Army Community HospitalEvans Army Community Hospital
2Patient Safety Is Job One
“Modern health care presents the most complex safety challenge of any activity on Earth.”
Lucian Leape, MDLucian Leape, MD
Father of Modern Patient Safety
3Patient Safety Is Job One
Newcomers’ Objectives1) Understand the EACH Patient Safety Goal
2) Accept the Patient Safety Expectations at
EACH (Patient Centered vs. Staff Centered)
3) Discuss Reporting Process
4) Apply the 2006 National PS Goals (6)
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4Patient Safety Is Job One
EACH Patient Safety GoalEACH Patient Safety Goal
Eliminate Eliminate preventable preventable
medical errorsmedical errors
5Patient Safety Is Job One
Patient Safety & the Joint Commission
• Sentinel Event Reporting Policy since 1995
• Change in Mission Statement in 2000
“To continuously improve SAFETY &
quality of care provided to the public”
• Additional PS Standards 2001
• Initiated National Patient Safety Goals 2003
6Patient Safety Is Job One
7Patient Safety Is Job One
0100002000030000400005000060000700008000090000
100000
FireDrowningPoisoningFallsMVAMed Errors
Lies, Damned Lies, and Lies, Damned Lies, and StatisticsStatistics
3700 4100 8400 16,600 41,200 98,000
Source: National Safety Council; Philadelphia Enquirer; Leape, MDcirca:1999
8Patient Safety Is Job One
JCAHO TOP SEs JCAHO TOP SEs (From 1995 – To 2005)
3,5483,548 (1,143) Sentinel Events Reviewed by JC
464 Patient Suicide 65 Fire455 Wrong Site Surgery 58 Anesthesia Related444 Op/Post-Op Complications 56 Medical Equipment Related358 Medication Error 51 Maternal Death269 Delay in Treatment 43 Ventilator Death/Injury189 Patient Falls 23 Infant Abduction/Wrong Family138 Patient Restraint Death/Injury 19 Utility Systems Related121 Assault/Rape/Homicide 13 Untended Foreign Body Retained109 Perinatal Death/Loss Function 446 Other less frequent types94 Transfusion Error 67 Infection Related Event 66 Patient Elopement
9Patient Safety Is Job One
DoD Top SEsDoD Top SEs (From 2000 – To 2005)
SE Event Category # %Wrong-Site/Procedure Surgery (1*) 13 (+7) 29
Op/Post-op Complication 10 22
Medication Related (2*) 8 (+2) 18
Delay in Treatment (5*) 7 15
Perinatal & Maternal Death (4*) 4 9
Other 3 7
*12 Events Resulted in Unanticipated Death
TOTAL
45 (+9)
10Patient Safety Is Job One
11Patient Safety Is Job One
12Patient Safety Is Job One
Top 3 Incidents at EACH Top 3 Incidents at EACH (2002 - 2005)(2002 - 2005)
Medication IssuesLaboratory IssuesPractice & Procedure
Variances
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Why Are We Here?
Variation is the Variation is the enemy of qualityenemy of quality
14Patient Safety Is Job One
The The “Swiss Cheese”“Swiss Cheese” Model of Accident Causation (Reason, 1990) Model of Accident Causation (Reason, 1990)
Excessive cost cutting – staffing reduction
Drive to Reduce Hospital Days
Long Working hours
Deficient training program
Inexperienced X-Ray Tech
Colleague Admitted Patient
Poor Coordination & Communication
Failed to review allergies
Wrong X-ray marker used
Wrong procedure performed
Failures in theSystem
Leadership
Policies/Procedures
Available Resources
Accident & InjuryWrong Site Surgery Medication Error Fall
“Latent Errors”
Barriers to
AccidentsCommunication
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Your ObligationYour Obligation
Every EACH employee has the Every EACH employee has the
responsibility and duty to question the responsibility and duty to question the
decision of any other team member, decision of any other team member,
without fear, at any time.without fear, at any time.
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18Patient Safety Is Job One
Nothing Will Change Unless You Change ItNothing Will Change Unless You Change It
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Patient Safety ProgramPatient Safety Program
Brief De-Brief Brief De-Brief Situational Awareness = Situational Awareness =
SBAR Situation SBAR Situation Background Background
Assessment Assessment Recommendation Recommendation
Gets Everyone On The Sheet of MusicGets Everyone On The Sheet of Music
20Patient Safety Is Job One
21Patient Safety Is Job One
James Reason’s Bottom LineJames Reason’s Bottom Line Fallibility is part of the human condition
We can’t change the human condition
So, we have to change the conditions under which people work
Father of Modern Safety Movement
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“Incompetent people are, at best, 1% of theproblem. The other 99% are good people trying todo a good job who make very simple mistakes andit’s the processes that set them up to make these
mistakes”Lucian Leape, MD
However, a no blame environment doesn’t mean the absence of accountability
Patient Centered vs. Staff Centered Care
What does this mean for you?
RealityReality
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23Patient Safety Is Job One
A culture that:
Does not advocate a name, blame, shame, and train philosophy,
Deny that errors occur only to “bad apples,”
Supports a fierce intolerance for intentional risk taking,
Fair treatment for individuals making errors regardless of outcome or frequency
Patient Centered vs. Staff Centered Care
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24Patient Safety Is Job One
16%16% 10%10%Not
Asked 19%19% 32%32% 6%6% 29%29%
MEDCOM 2003 Survey n = 5,763
As of August 2005
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Tools Available to Combat System Errors
FMEAFMEA
RCARCA
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Failure Mode and Effect Analysis
(FMEA) is a systematic method of
identifying and preventing process problems before they occur.
“Think of it as Preventive Medicine for Our Health Care System.”
What is FMEA?What is FMEA?
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ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS
A tool used to systematically and objectively identify process and system “errors” resulting in variation in performance.
It’s the Post Mortem (Autopsy) for a Specific Area of Our Health Care System.
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Root Cause AnalysisFailure Mode and Effects
Analysis
Reactive Proactive
Focuses on a Specific Patient Course of
Treatment
Focuses on an entire process
Hindsight bias Unbiased
Asks “Why?” Asks “What if?”
Differences Between Differences Between RCARCA and and FMEAFMEA
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Your Duty is to . . . Your Duty is to . . . • Report, Report, Report!Report, Report, Report!
• Make Situational Awareness HappenHappen
• Make Patient Safety Priority
• Be Proactive
• Use our e-4106 ProgramUse our e-4106 ProgramGo to EACH’s Home Page To Access
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Reporting incidents improves patient care.
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Note: Paper Note: Paper 4106s are 4106s are No Longer No Longer AcceptedAccepted
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Note: Anyone Note: Anyone with an AMEDD with an AMEDD
e-mail address e-mail address can submit an can submit an
e-4106 e-4106
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1. Patient Identification 2. Communication Among Caregivers 3. Medications Safety *7. Risk Reduction Acquired Infections
8. Medication Reconciliations 9. Reduce Patient Falls
Goals 4, 5, & 6 were retired and included in the JCAHO CAMH Standards.•New Goals are Bolded.
JCAHO 2006National Patient Safety
Goals
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Patient Safety means Patient Safety means NEVERNEVER being being the LAST TO KNOW!the LAST TO KNOW!
35Patient Safety Is Job One
Patient Safety Officerx6-7190